There are several new changes to the Joint Commission Standards for 2009. One of the biggest changes directly affects the transplanting of tissues and organs.
- Transplant Safety (TS) is now its own Gold Chapter and a hospital must meet all the Elements of Performance (EP) in this chapter as a “Requirement for Accreditation”
What this means: The Joint Commission surveyor will spend time doing tracers and reviews on your entire tissue program.
- The new TS chapter requires more Documentation and new Measures of Success.
What this means: A Measure of Success (MOS) is needed. An MOS is defined as a quantifiable measure, usually related to an audit, which will be used to determine whether an action has been effective and is being sustained.
- There are now six Elements of Performance (EP) that are critically tagged and fall under the “Direct Impact Requirement” {TS .03.01.01 #5, #10} {TS .03.02.01 #1} {TS .03.03.01 #3, #4, #5}
What this means: If one or more Direct Impact EPs under a standard are found to be partially or insufficiently compliant, then all EPs under that standard must be addressed in an Evidence of Standards Compliance (ESC) within 45 days. Failure to send in the ESC or the MOS can result in either conditional accreditation or even denial of accreditation, or an unannounced on-site validation survey to see if you have made the required changes.
- Tissue TrackCore (TTC) is the only tissue tracking compliance software to be reviewed by the Joint Commission Resources. TTC can help you simply and efficiently meet all of the new standards with minimum impact on your staff.
What this means: For the cost of a couple of pieces of tissue you can not only ensure compliance, but also save time and reduce costs by purchasing the market leading software solution.
